The authors have checked with sources believed to be reliable in their efforts to provideinformation that is complete and generally in accord with the standards of practicethat are accepted at the time of publication. However, in view of the possibility ofhuman error or changes in behavioral, mental health, or medical sciences, neither theauthors, nor the editors and publisher, nor any other party who has been involved in thepreparation or publication of this work warrants that the information contained hereinis in every respect accurate or complete, and they are not responsible for any errorsor omissions or the results obtained from the use of such information. Readers areencouraged to confirm the information contained in this book with other sources.Library of Congress Cataloging-in-Publication DataDuPaul, George J. ADHD in the schools : assessment and intervention strategies / George J. DuPaul,Gary Stoner.—Third edition. pages cm Includes bibliographical references and index. ISBN 978-1-4625-1671-1 (hardback) 1. Attention-deficit-disordered children—Education—United States. 2. Attentiondeficit hyperactivity disorder—Diagnosis. I. Stoner, Gary. II. Title. LC4713.4.D87 2014 371.93—dc232014006560

To the many students with ADHD, families, and teacherswith whom we have worked over the course of our careers.We have learned a great deal from them,and we truly hope that learning is represented well enoughin this text to be of help to others.

About the Authors

George J. DuPaul, PhD, is Professor of School Psychology at Lehigh­University. He is a Fellow of Divisions 16 (School Psychology), 53 (Clinical Child and Adolescent Psychology), and 54 (Pediatric Psychology) ofthe American Psychological Association (APA) and is past president ofthe Society for the Study of School Psychology. Dr. DuPaul is a recipientof the APA Division 16 Senior Scientist Award and was named to theChildren and Adults with ADHD Hall of Fame. His primary researchinterests are school-based assessment and treatment of disruptive behavior disorders, pediatric school psychology, and assessment and treatmentof college students with ADHD. Dr. DuPaul’s publications include over190 journal articles and book chapters on assessment and treatment ofADHD, as well as the coauthored ADHD Rating Scale–IV.Gary Stoner, PhD, is Professor in the Department of Psychology andDirector of the Graduate Programs in School Psychology at the University of Rhode Island. He is a Fellow of the APA, past president ofAPA Division 16, and a member of the Society for the Study of SchoolPsy­chology. Dr. Stoner’s research interests include prevention and intervention with achievement and behavior problems, early school success,­parent and teacher support, and professional issues in school psychology. He is past chair of the APA’s Interdivisional Coalition for Psychology in Schools and Education and currently serves on the APA Commission on Accreditation.vi

Foreword

Attention-deficit/hyperactivity disorder (ADHD) is a problem thataffects millions of students. In the United States, it is now the most commonly diagnosed psychological disorder of childhood. Worldwide prevalence is estimated at 5% among school-age children, but in the UnitedStates recent researchers have reported that over 10% of school-age students have been identified or considered as having ADHD.ADHD is also a serious problem for our society. It is a chronic,lifelong disorder. Individuals with ADHD have an increased risk for alitany of serious problems. For children, risks include lower academicachievement and increased risk for learning disabilities, conduct disorder, or depression. Additionally, they are likely to encounter serious difficulty in social settings, which can result in social isolation. As childrenwith ADHD enter adolescence, they are more likely than their peers toexperience incarceration, contract a sexually transmitted disease, or beinvolved in multiple car accidents. While some symptoms may abate overtime, the core problems remain through adulthood. Adults with ADHDare more likely than peers to be underemployed or unemployed.In the United States, the direct cost of ADHD (e.g., medical costs,educational services) is estimated to be approximately $50 billion peryear. Indirect costs (e.g., lost work time by family members) are difficultto quantify but may be even higher. In sum, ADHD poses clear individual, social, and economic concerns.As one might expect, ADHD is quite possibly the most thoroughlystudied psychological disorder in history. Searching an online databasevii

viii

Foreword

reveals that there are well over 10,000 scientific papers written on various aspects of ADHD. ADHD also has received a tremendous amountof attention in the media. Cover stories on ADHD appear regularlyin national news magazines, and stories on ADHD appear frequentlyin broadcast media. However, even this amount of attention pales incomparison to the sources available on the Internet. Truly, there is anocean of information on ADHD. Unfortunately, far too often, accountsof ADHD in the popular media or on the Internet are sensationalized orunrepresentative. The media often focus on dramatic first-person storiesof success or failure. They chronicle an uplifting but atypical accountof how a child overcame ADHD or, conversely, how the problems ofADHD led to other, much more serious problems. Websites hawk thelatest “miracle cures,” which—as regular as clockwork—will soon bereplaced by the next nostrum. Other stories report on purported causesof ADHD.Coverage commonly focuses on controversies. There is now a cottage industry of critics who focus on disputes—real or contrived—surrounding ADHD or the “uncertainties” of scientific knowledge—“uncertainties” that often are created from whole cloth by those withtheir own agendas. As a result, ADHD may seem shrouded in mystery;many people are unaware of exactly what ADHD is and how it affectsindividuals and ultimately society. Perhaps for this reason, there arenumerous misconceptions about ADHD. Some of these misconceptionshave attained mythic status, and are persistent, persuasive, and unrealistic. Unfortunately, these myths can have an effect on how ADHD isperceived and how educators respond to ADHD.It is true that scientists do not totally understand the phenomenonof ADHD. This is partly because ADHD is a complex, multifaceted disorder. Children with ADHD are a highly heterogeneous group who candiffer markedly even though they have the same diagnosis. Additionally, because different adults (e.g., parents, teachers) see a child in different environments that place different demands and expectations on thechild, they may differ on their opinion of the child’s problem.The combination of information (and misinformation) overload andcomplexity poses a grave problem for educators, who are at the frontlines of ADHD treatment. Children and adolescents with ADHD spendover 1,000 hours annually in the schools. Other professionals (e.g., physicians, psychiatrists, psychologists) have only a minute fraction of thecontact hours with individuals with ADHD that educators have. Successin school is crucial for these students, and it is an attainable goal. Butit is not easily achieved, and requires educators to have solid, scientificinformation on crucial factors of ADHD that impact students’ performance in the schools.

Forewordix

George J. DuPaul and Gary Stoner obviously are well aware of thecritical need educators have for reliable information on this disorder.Based on my experience in the field, I can think of no individuals whoare more qualified to provide this information. Both authors are widelyhailed as among the preeminent scholars in the area of ADHD and theschools. Both have decades of practical experience working with theschools and in conducting research in assessment and treatment of students with ADHD. Both are keenly sensitive to the critical knowledgeof ADHD that educators need to work successfully with these students.Most important, all of the information provided is based on the best,most up-to-date scientific evidence available, and is refreshingly free ofbias or any outside agendas. It is quite obvious that the authors’ onlyinterest is in providing educators the most accurate information possibleon the topic.In this volume the authors have distilled the ocean of informationinto a manageable body that neither overwhelms potential readers norskimps on critical information. They provide background knowledgealong with an excellent treatment of controversies and fallacies aroundADHD. Assessment and screening of ADHD and the schools’ role in theprocess is discussed. A detailed section on interventions can inform educators on how best to address common problems posed by students withADHD. Medication, one of the most contentious areas of ADHD treatment, is thoroughly covered in a highly balanced manner. The authorsalso provide an excellent section on working with parents of studentswith ADHD, which is a crucial factor in treatment.All in all, this book, now in its third edition, remains an invaluablereference for educators. It is a volume no teacher who works with students with ADHD should be without. The authors are to be commendedfor yet again providing an invaluable resource.Robert R eid, PhDUniversity of Nebraska–Lincoln

Preface

Students who display inattentive and disruptive behavior present significant challenges to educational professionals. In fact, many children andadolescents who exhibit behavior control difficulties in classroom settings are diagnosed as having an attention-deficit/hyperactivity disorder(ADHD). Students with ADHD are at high risk for chronic academicachievement difficulties; the development of antisocial behavior; andproblems in relationships with peers, parents, and teachers. Traditionally, this disorder has been identified and treated by clinic-based professionals (e.g., pediatricians, clinical psychologists) on an outpatientbasis. Given that children and adolescents with ADHD experience someof their greatest difficulties in educational settings, it is important forschool-based professionals to directly address the needs of students withthis disorder. In addition, federal regulations governing special education eligibility have magnified the need for educators to receive trainingin assessing and treating students with ADHD in the schools. The purpose of this book is to assist school professionals in understanding andtreating children and adolescents with ADHD.When the first edition of this book was published in 1994, researchand evaluation activities relating to children and adolescents with ADHDwere primarily the realm of pediatricians, psychiatrists, and clinic-basedpsychologists; few school-based studies of the activities, functioning,and development of children with ADHD had been conducted. This situation has changed dramatically since then. We now see school-focusedresearchers, empirical investigations, and school-based issues regardingxi

xii

Preface

ADHD becoming prevalent in the research literature and as topics at professional conferences. In this third edition, we have attempted to addressthe problems associated with ADHD from a school-based perspective,while recognizing the need for a team effort among parents, community-based professionals, and educators. Specifically, we have focusedon how to (1) identify and assess students who might have ADHD; (2)develop and implement classroom-based intervention programs for thesestudents; (3) identify and provide early intervention to young children atrisk for ADHD; and (4) communicate with and assist physicians whenpsychotropic medications are employed to treat this disorder.In this third edition, we have updated information in these majorareas to address the understanding and management of ADHD in acomprehensive fashion for school-based professionals. In addition, wedescribe assessment and intervention strategies for college students withADHD and provide expanded coverage of associated behavior disordersas well as assessment and treatment approaches for secondary schoolstudents with ADHD.This book is intended to meet the needs of a variety of school-basedpractitioners, including school psychologists, guidance counselors, andadministrators, as well as both general and special education teachers.Given that students with ADHD are found in nearly every school settingand experience a wide range of difficulties, there should be somethingof interest to all professional groups in this text. In addition, graduatestudents who are receiving training in a variety of school-based professions should find this book helpful in understanding this complex disorder. This is our attempt to contribute to continued forward movementof improved school-based practices, services, and supports for childrenand adolescents identified with ADHD. We sincerely hope readers findthis volume to be useful in influencing both professional perspectiveson ADHD in schools and the professional work of all those providingservices to students with ADHD.

Acknowledgments

As was the case with the first and second editions, this book wouldnot have reached fruition without the support and encouragement of avariety of people. We continue to owe a great deal to our former mentor and major professor, Dr. Mark Rapport of the University of CentralFlorida. His enthusiasm for the scientific study of ADHD combinedwith his emphasis on conducting investigations that are clinically andpractically relevant provided us with an exemplar of the scientist-practitioner model in action. Furthermore, the high scientific and academicstandards that he set for us and other graduate students have led, atleast indirectly, to the completion of this book. We also continue to beinspired by the work of Dr. Russell A. Barkley of the Medical University of South Carolina. One of the true “giants” in the field of ADHDresearch, his support and guidance were critical to the preparation ofthe first edition of this text.Next, we are grateful for the support and encouragement of ourcolleagues Drs. Arthur Anastopoulos, Christine Cole, John Hintze,Robin Hojnoski, Lee Kern, Patti Manz, William Matthews, ThomasPower, Edward Shapiro, Terri Shelton, Mark Shinn, and Lisa Weyandt.Our students at Lehigh University and the University of Rhode Island,too numerous to name, have also been supportive and patient throughout the time that we were preparing this book. Our continued success is directly related to the innovative ideas and challenges presentedby our students. We specifically appreciate the assistance provided byxiii

xiv

Acknowledgments

Sarah Cayless-Patches in double-checking and finalizing our referencesection.Great levels of patience and support were evidenced by our families, specifically our spouses, Judy Brown-DuPaul and Joyce Flanagan,respectively. Their willingness to tolerate “lost” evenings and weekendswill not go unrewarded. We remain indebted to the editorial staff at TheGuilford Press, most especially Natalie Graham, for continuing to support our work with the ideal blend of patience and prodding.

Contents

Chapter 1.

Overview of ADHD

1

Prevalence of ADHD 4School‑Related Problems of Children with ADHD 5Subtypes of ADHD 9Possible Causes of ADHD 17The Impact of Situational Factors on ADHDSymptom Severity 21Long‑Term Outcome of Children with ADHD 23Overview of Subsequent Chapters 26

Chapter 2. Assessment of ADHD in School Settings

29

The Use of Diagnostic Criteria in the School‑BasedAssessment of ADHD 30Overview of Assessment Methods 33Stages of Assessment of ADHD 36Developmental Considerations in the Assessmentof ADHD 62Implementation of the Assessment Model 64Case Examples 65Involvement of School Professionalsin the Assessment Process 71Summary 72

ADHD in Young Children 106Screening and Diagnostic Procedures 110Early Intervention and Prevention Strategies 118Community‑Based Prevention and Intervention 122Multicomponent Early Intervention:Findings and Future Directions 136Summary 141

Recommendations for Working with Studentswith ADHD: Current and Future Directions 297Conclusions 304

References

305

Index

355

Purchasers can download and printlarger versions of selected appendicesfrom www.guilford.com/p/dupaul.

Ch a p ter 1

Overview of ADHD

Amy, Age 4Amy is a 4-year-old girl who lives with her mother, stepfather, andyounger brother (age 2). She attends preschool four mornings perweek at a local church. Her mother reports Amy was “a terror” asan infant. She was colicky, frequently cried, and demanded to be held“constantly.” At about 11 months old, when she began walking, Amy’sactivity level increased and she “was always into everything.” In fact,on one occasion when Amy was 2 years old, she was brought into theemergency room following ingestion of some cleaning fluids that shehad found under the kitchen sink. Amy has been asked to leave severaldaycare and nursery school settings because of her high activity level,short attention span, and physical aggression toward peers. Althoughshe is beginning to learn letters and numbers, it is very difficult forher mother or teacher to get her to sit still for any reading or learningactivities. Amy’s preference is to engage in rough-and-­tumble activitiesand she can become quite defiant when asked to sit and complete morestructured or quiet activities (e.g., drawing or coloring).Greg, Age 7Greg is a 7-year-old first grader in a general education classroom in apublic elementary school. According to his parents, his physical andpsychological development was “normal” until about age 3 when hefirst attended nursery school. His preschool and kindergarten teachers reported Greg to have a short attention span, to have difficultiesstaying seated during group activities, and to interrupt conversationsfrequently. These behaviors were evident increasingly at home aswell. Currently, Greg is achieving at a level commensurate with his1

ADHD IN THE SCHOOLS

2

classmates in all academic areas. Unfortunately, he continues to evidence problems with inattention, impulsivity, and motor restlessness.These behaviors are displayed more frequently when Greg is supposedto be listening to the teacher or completing an independent task. Histeacher is concerned that Greg may begin to exhibit academic problemsif his attention and behavior do not improve.Tommy, Age 9Tommy is a fourth grader whose schooling occurs in a self-­contained,special education classroom for children identified with emotional–­behavior disorders in a public elementary school. His mother reportsthat Tommy has been a “handful” since infancy. During his preschoolyears, he was very active (e.g., climbing on furniture, running aroundexcessively, and infrequently sitting still) and noncompliant withmaternal commands. He has had chronic difficulties relating to otherchildren: he has been both verbally and physically aggressive with hispeers. As a result, he has few friends his own age and tends to play withyounger children. Tommy has been placed in a class for students inneed of social–­emotional support since second grade because of his frequent disruptive activities (e.g., calling out without permission, swearing at the teacher, refusing to complete seatwork) and related problematic academic achievement. During the past year, Tommy’s antisocialactivities have increased in severity: he has been caught shoplifting onseveral occasions and has been suspended from school for vandalizingthe boys’ bathroom. Even in his highly structured classroom, Tommyhas a great deal of difficulty attending to independent work and following classroom rules.Lisa, Age 13Lisa is a 13-year-old eighth grader who receives most of her instruction in general education classrooms. A psychoeducational evaluationconducted when she was 8 years old indicated a “specific learning disability” in math, for which she receives resource room instruction threeclass periods per week. In addition to problems with math skills, Lisahas exhibited significant difficulties with inattention since at least age5. Specifically, she appears to daydream excessively and to “space out”when asked to complete effortful tasks either at home or at school.Her parents and teachers report that she “forgets” task instructionsfrequently, particularly if multiple steps are involved. At one time, itwas presumed that her inattention problems were caused by her learning disability in math. This does not appear to be the case, however,because she is inattentive during most classes (i.e., not just during mathinstruction) and these behaviors predated her entry into elementaryschool. Lisa is neither impulsive nor overactive. In fact, she is “slow torespond” at times and appears reticent in social situations.

Overview of ADHD3

Roberto, Age 17Roberto is a 17-year-old student who attends the 10th grade in a largeurban high school. He was retained in grade twice during elementaryschool and has struggled academically throughout his academic career.Furthermore, his teachers described him as impatient, disruptive, restless, and lacking in motivation. As a result of his academic and behavior difficulties, Roberto has been provided with a variety of specialeducation services, including placement in a learning support classroom, individual counseling, and, briefly, placement in an alternativeschool environment. Furthermore, school professionals have attemptedto involve Roberto’s family with community-­based counseling servicesand have recommended consultation with his physician regardingpsychotropic medication; these recommendations have been followedinconsistently over the years. Despite these services, Roberto’s difficulties have worsened and have been compounded in recent years by hisinvolvement in a local gang. He has been arrested on two occasions forshoplifting and vandalism and also is truant from school quite often.He has asked his parents to allow him to drop out of high school sothat he can obtain a full-time job.Jeff, Age 19Jeff is a 19-year-old sophomore attending a private, liberal arts college. He was diagnosed with ADHD, combined type, when he was inelementary school owing to his frequent inattentiveness and impulsivebehavior. Jeff’s ADHD symptoms were controlled to some degree by thecombination of stimulant medication and behavioral strategies implemented by his parents and classroom teachers. As a result, Jeff wasable to obtain above-­average grades in most academic areas, althoughhe struggled with being prepared for class and studying for tests. Hewas provided with accommodations such as extra time on tests andreduced homework assignments. With support and extra time, Jeff wasable to obtain competitive scores on the SAT, thus providing him withseveral options for college. His adjustment to college has been challenging given increased demands for independence and self-­regulation.The student disabilities office provides Jeff with academic tutoring andcoaching in organizational skills; he also continues to receive educational accommodations. Jeff has an overall grade point average (GPA)of 2.5 with variable performance across subject areas.

Although the six individuals described above are quite different,they share a common difficulty with attention, particularly to assignedschoolwork and household responsibilities. Furthermore, many childrenwith attention problems, such as Amy, Greg, Tommy, and Roberto, display additional difficulties with impulsivity and overactivity. The current psychiatric term for children exhibiting extreme problems with

4

ADHD IN THE SCHOOLS

inattention, impulsivity, and hyperactivity is attention-­deficit/hyperac‑tivity disorder, or ADHD1 (American Psychiatric Association, 2013). Ascan be discerned from the above case descriptions, the term ADHD isapplied to a heterogeneous group of students who are encountered invirtually every educational setting from preschool through college.The purpose of this chapter is to provide a brief overview of ADHD.Specifically, we review information regarding the prevalence of this disorder, the school-­related problems of children with ADHD, associatedadjustment difficulties, methods of subtyping children with this disorder, possible causes of ADHD, the impact of situational factors on symptom severity, and the probable long-term outcomes for this population.This background material provides the context for later descriptions ofschool-­based assessment and treatment strategies for ADHD.

Prevalence of ADHDEpidemiological (i.e., population survey) studies indicate that approximately 3–10% of children in the United States can be diagnosed withADHD (Centers for Disease Control and Prevention [CDC], 2010;Froehlich et al., 2007) with a median estimate of 6.8% across multiplenational surveys (Centers for Disease Control and Prevention, 2013).Because most general education classrooms include at least 20 students,it is estimated that one child in every classroom will have ADHD. Asa result, children reported to evidence attention and behavior controlproblems are frequently referred to school psychologists and other education and mental health professionals. Boys with the disorder outnumbergirls in both clinic-­referred (approximately a 6:1 ratio) and community-­based (approximately a 3:1 ratio) samples (Centers for Disease Controland Prevention, 2010, 2013; Froehlich et al., 2007). The higher clinicratio for boys with this disorder may be a function in part of the greaterprevalence of additional disruptive behaviors (e.g., noncompliance, conduct disturbance) among boys with ADHD (Gaub & Carlson, 1997).More than 50% of children diagnosed with ADHD receive psychotropic medication for this condition, while approximately 12% and 34%receive special education and mental health services, respectively (Pastor& Reuben, 2002). Thus, relative to other childhood conditions (e.g.,autism and depression), ADHD is a “high-­incidence” disorder that is1 Because

multiple labels for attention-­deficit/hyperactivity disorder have been usedthroughout the years and across disciplines, the term ADHD will be used in this textto promote simplicity. ADHD will be considered synonymous with other terms forthe disorder, such as hyperactivity and ADD.